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ICAK 2007
Leon Chaitow ND DO
University of Westminster, London
www.leonchaitow.com
Recognising, understanding &
rehabilitating breathing pattern
disorder (BPD) influences on low back
and pelvic pain
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Tribute to a great man :
George Goodheart DC
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Greatest Influence?Reflecting on Dr Goodheart’s influence on my work I realise how his
example has taught me to look wide, to keep an open mind, to
synthesize and - above all - to simplify.
The example that most clearly illustrates this relates to Jones’
Strain/Counterstrain, which he turned from an brain-numbing
exercise, calling for the memorizing of hundreds of possible point
locations in relation to particular strains - by offering in its place a
formula of such elegent simplicity that it is possible to teach it to
patients for home care in a few minutes!
That takes pure genius.
In Positional Release Techniques, I offer Jones’s approach - and also
‘Goodheart’s Guidelines’. Guess which most people choose to use?
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AK and Naturopathy
Both systems attempt to focus on the whole person - their inherited,
acquired and current features & characteristics - as well as the
context out of which dysfunction emerges
This is true integrated health care, and despite differences in
methodology they have a great deal in common, both in practice,
and certainly in theory and understanding of the processes involved
in health, disease, and our self-regulatory systems.
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‘Eclectic & inspirational’ are the key words I think of in
association with Dr Goodheart’s work.
In many ways his thinking is as much naturopathic &
osteopathic, as chiropractic (and I can offer no greater
compliment). His assiduous ability to see to the heart of
therapeutic concepts, along with his talent for synthesizing
elements from osteopathy, TCM, chiropractic and more,
have been an inspiration.AK
Osseous and soft tissue normalization
Posture/gait
Neurolymphatic & Neurovascularreflexes
Craniosacral system
Meridian balancing
Jones’s Strain/counterstrain
Neural receptor treatment
etc etc etc etc …… and more…….
Thank you Dr Goodheart !
!
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To achieve better oxygenation under
normal conditions does NOT require
deep breathing - it requires optimal
retention of CO2.
Hyperventilation is normal when
running, during states of acidosis,
during late pregnancy.
A major key to better oxygenation is an
inhalation:exhalation ratio of about 1:2
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BPD Rehab EssentialsRecognise BPD (including Nijmegen test &/or capnography)and help patient realise that :a. His/her BPD is real b. His/her BPD is a habit that can change, ….but only if c. Homework is done at same time that structuralmobilization/stabilization is being achieved.Also……ensure nutritional and psychosocial issues are considered1. Where does breathing occur - Observe, Palpate, HiLo test etc2. Identify what’s short/what’s tight (?use functional tests?)3. Release what’s short, facilitate (tone) what’s weak (?TrPts?) -including: Diaphragm, Scalenes, SCM, Pectorals, Upper traps, QL, Psoas
4. Identify spinal and rib restrictions - mobilise or manipulate(HVLA, MWM, PRT, Pulsed MET, MET, MFR etc etc)5. Utilise specialised methods (e.g. rib raising)6. Simultaneously commence breathing rehab including :
- Pursed-lip breathing/antiarousal breathing
- Breaking link between inhalation & activation of accessory respiratory muscles
- Use capnotrainer if available…….- Suggest appropriate activities - Tai chi, Chi Gung, Yoga…….- Move from retraining when calm to doing so in challenging situations.
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Nijmegen questionnaireRare=less than monthly. Sometimes = more than monthly, less than weekly.
Often = at least weekly, but not daily. Very often = at least daily.
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Contextual thinking: BPD & Anxiety
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Thyroid - Hyperventilation Connection“In patients with severe hypothyroidism, the ventilatory
control system may be altered at the neural level.”Duranti R 1993 Control of breathing in patients with severehypothyroidism American Journal of Medicine 95(1):29-37
“In patients with hypothyroidism, diaphragmatic
dysfunction occurs more frequently than has beensuspected and might be of varying severity”Martinez F et al 1989 Hypothyroidism. A reversible cause ofdiaphragmatic dysfunction Chest (96)5:1059-1063
“Severely hypothyroid patients are at risk for adverseevents around the time of surgery …. more sensitive toanaesthetics, higher incidence of surgery-relatedcardiovascular disease, increased risk for ventilatoryfailure following surgery”Lee H Levine M 1999 Acute respiratory alkalosis associated withlow minute ventilation in a patient with severe hypothyroidism.Can. J. Anaesth., 46(2):185-189
NOT IN HANDOUT NOTES
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Posterior Crossed Pattern & Pelvic Floor DysfunctionCharacterised by:-
• Pelvis - posterior shift + increased anterior sagittal tilt.
• Trunk - anterior translation of thorax
• Increased lordosis at thoraco-lumbar junction
Hypoactivity/ lengthened:-
o Entire abdominal wall and pelvic floor
o Lumbosacral multifidus
o Inefficient diaphragm activity
Hyperactivity / adaptive shortness:-
o Thoraco lumbar erector spinae +++
o Anterior hip flexor groups primarily psoas.
o Piriformis.
o Hip internal rotators › external rotators
Trunk extension reduced
Thoraco-lumbar region hyperstabilised
Poor pelvic control
Decreased hip extension
Abnormal axial rotation
Dysfunctional breathing patterns
Pelvic floor dysfunctionNOT IN HANDOUT NOTES
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Anterior Crossed Pattern & Pelvic Floor DysfunctionCharacterised by:-
• Pelvis - anterior shift + increased posterior tilt
• Trunk (thorax) backward loaded –lumbar spine flexed
• Hips in extension - tight posterior hip structures
• No buttocks, head forward, kyphosis, knees extended
Hypoactivity/lengthened:
o Lower abdominal group and pelvic floor
o Lumbar multifidus – particularly over lower levels.
o Diaphragm – reduced excursion ++
o Iliacus; Psoas.
o Glutei
Hyperactivity / adaptive shortness:
o Hamstrings
o Piriformis
o Upper abdominal group + lateral internal oblique
o Hip external rotators › internal rotators
Flexors tend to dominate
Loss of extension through spine
Thoraco lumbar junction hyperstabilised in flexion
Poor pelvic control
Dysfunctional breathing Patterns
NOT IN HANDOUT NOTES
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STRATIFICATION or LAYER SYNDROME. (Janda 1987)
Observed from behind - ‘banding’ of the extensor system:-
• Overactive and / or tight: - cervical erector spinae; upper trapezius;
levator scapulae; thoraco lumbar erector spinae; piriformis, hamstrings.
• Underactive: - lower scapular stabilisers; lumbosacral multifidus;
gluteus maximus. NOT IN HANDOUT NOTES
Observed from front - ‘banding’ in flexor activity as:-
• Overactive and / or tight: - sternocleidomastoid;
pectorals; oblique abdominals;
• Underactive: - Deep neck flexor group; abdominal
weakness particularly transversus and rectus abdominis
Janda V. 1987. Muscles and motor control in low back pain – assessment and
management In: Twomey L. editor. Physical Therapy of the Low Back (first edition),
Churchill Livingstone 253-278
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Belted Torso SyndromeMuscle hypoactivity/poor control of posture & movement above belt
•Posteriorly - Central Posterior Cinch (CPC)**
•Central - Anterior Cinch (CAC)
•Combination - inferior thoracic cage becomes apex of inverted cone
(Central Conical Cinch - CCC)
Hypoactivity/poor control of posture & movement below belt
Anteriorly:-
•Whole abdominal wall in PPXS##; lower abd. wall in APXSxx
Posteriorly:-
•Lower lumbar multifidus underactive in PPXS & APXS
•Upper levels underactive in APXS
Centrally:-
•Diaphragm inefficient
•Iliacus and Psoas underactive in APXS; imbalanced in PPXS (psoas over, iliacus
underactive).
•Pelvic floor muscles dysfunctional
** A cinch is a wide strap that attaches a saddle to a horse##PPXS = posterior pelvic crossed syndromexx APXS= anterior pelvic crossed syndrome
NOT IN HANDOUT NOTES
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Over-emphasis on core control = core regidityClinically there is relationship between pelvic floor
dysfunction syndromes and CPC and CCC muscle activation
patterns which hyperstabilise thoraco-lumbar region, creating
segmental joint dysfunction and resultant autonomic effects.
Overemphasis on abdominal strengthening can lead to
misapplied “core control”. Particularly in those with APXS
where it can lead to loss of the lordosis as well as disturbed
breathing. NOT IN HANDOUT NOTES
Over- applied core stability training can become ‘core rigidity
training’ -inducing central fixing behaviour around the body’s
centre of gravity + associated dysfunctional breathing patterns- O’Sullivan P. 2005. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control
impairments as an underlying mechanism. Manual Therapy 10: 242-255
- Comerford M. 2001. What comes first – the pain or the dysfunction? – Integration of local and global stability systems in rehab. In:
Proc. 1st International Conference on Movement Dysfunction, Edinburgh
- Hanna T. 1988. Somatics – reawakening the mind’s control of movement and flexibility and health Publ. Da Capo Press.
- Thompson J et al 2004. Motor control strategies for activation of the pelvic floor. Proc. 5th Interdisciplinary World Congress on low
back and pelvic pain. Melbourne
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NOT IN HANDOUT NOTES Pelvic floor influencesHodges & Cholewicki (2007) observe that the pelvic
floor muscles indirectly contribute towards spinal
stability via pressure and tension in the thoraco-
lumbar fascia, as well as contributing to SIJ
stability, particularly in women. If pelvic floor
muscles are dysfunctional, spinal support may be
compromised, increasing oblquus externus activity,
overcoming pelvic floor muscle activity, and
resulting in incontinence (Smith 2007)
Hodges P Cholewicki J 2007 Functional control of the Spine. IN:Vleeming A
Mooney V Stoekart R (Eds) Movement stability & lumbopelvic pain. Churchill
Livingstone/Elsevier. Edinburgh.
Smith M et al Postural response of the pelvic floor and abdominal muscles in
women with and without incontinence. Neurourology and Urodynamics (in press)
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Obturator trigger points
Line drawing of a dissection of the left
gluteal region with the gemelli
superior, gemelli inferior, and the
obturator internus muscles intact.
Superior is to the left of the figure
and medial is to the top of the figure
legspine
buttock
NOT IN HANDOUT NOTES
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Releasing/stretching Obturator
Manual stretching of the gemelli–obturator
internus and piriformis muscles
Mechanical stretching of the tendons and
muscles of the gemellus inferior and superior,
piriformis, and obturator internus at their
insertion into the greater trochanter of the
femur: compression together with abduction
Cox J Bakkum B 2005 Possible
generators of retrotrochanteric
gluteal and thigh pain: the
gemelli–obturator internus
complex Journal of Manipulative
& Physiological Therapeutics
28(7):534:53
NOT IN HANDOUT NOTES
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Example of Load Transfer Failure
Stress urinary incontinence sneeze
(A) In patients with SUI who have weak abdominal muscles, the sneeze
inspiratory effort may be similar to that in healthy subjects. There is often less
abdominal wall excursion and more rib cage movement.
(B) During the expiratory phase, the abdominal wall bulges forward and the PFM
are forced down.Sapsford R 2003 Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Manual
Therapy 9(1):3-12 NOT IN HANDOUT NOTES
Normal sneeze
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Breathing disorders and cranial features
NOT IN HANDOUT NOTES
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Cranio-facial approachesNOT IN HANDOUT NOTES
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Yoga
assanas for
respiratory
and pelvic
floor
balance?IN PRESS
NOT IN
HANDOUTS